Suzanne M. Yandow

A Randomized Clinical Trial Comparing Intralesional Bone Marrow and Steroid Injections for Simple Bone Cysts

BACKGROUND Simple bone cysts are common benign lesions in growing children that predispose them to fracture and are sometimes painful. The purpose of this trial was to compare rates of healing of simple bone cysts treated with intralesional injections of bone marrow with rates of healing of those treated with methylprednisolone acetate. METHODS Of ninety patients randomly allocated to treatment with either a bone-marrow or a methylprednisolone acetate injection, seventy-seven were followed for two years. The primary outcome, determined by a radiologist who was blind to the type of treatment, was radiographic evidence of healing. The cyst was judged to be either not healed (grade 1 [a clearly visible cyst] or grade 2 [a cyst that was visible but multilocular and opaque]) or healed (grade 3 [sclerosis around or within a partially visible cyst] or grade 4 [complete healing with obliteration of the cyst]). Patient function was assessed with use of the Activity Scale for Kids, and pain was assessed with the Oucher Scale. RESULTS Sixteen (42%) of the thirty-eight cysts treated with methylprednisolone acetate healed, and nine (23%) of the thirty-nine cysts treated with bone marrow healed (p = 0.01). There was no significant difference between the treatment groups (p > 0.09) with respect to function, pain, number of injections, additional fractures, or complications. CONCLUSIONS Although the rate of healing of simple bone cysts was low following injection of either bone marrow or methylprednisolone, the latter provided superior healing rates.

Deficiency of the α‐Subunit of the Stimulatory G Protein and Severe Extraskeletal Ossification

Progressive osseous heteroplasia (POH) is a rare disorder characterized by dermal ossification beginning in infancy followed by increasing and extensive bone formation in deep muscle and fascia. We describe two unrelated girls with typical clinical, radiographic, and histological features of POH who also have findings of another uncommon heritable disorder, Albright hereditary osteodystrophy (AHO). One patient has mild brachydactyly but no endocrinopathy, whereas the other manifests brachydactyly, obesity, and target tissue resistance to thyrotropin and parathyroid hormone (PTH). Levels of the α‐subunit of the G protein (Gsα) were reduced in erythrocyte membranes from both girls and a nonsense mutation (Q12X) in exon 1 of the GNAS1 gene was identified in genomic DNA from the mildly affected patient. Features of POH and AHO in two individuals suggest that these conditions share a similar molecular basis and pathogenesis and that isolated severe extraskeletal ossification may be another manifestation of Gsα deficiency.

Femoral-shaft fractures in children : A comparison of immediate casting and traction

Two hundred fifty-three femoral-shaft fractures in 246 pediatric patients treated between 1976 and 1986 were retrospectively reviewed, and 186 fractures in 181 patients were available for demographic review. Fifty-nine patients underwent spica casting within 48 h of injury, whereas 127 were placed in traction and underwent delayed casting (>48 h from injury). Fifty-five patients in the traction group and 33 in the immediate-casting group were locatable for long-term follow-up of 8.9 years average (range, 4-20 years). There was no clinically significant difference in limb-length inequalities, or rotational or angular deformities between the two groups at initial casting or at final follow-up. Hospital stay averaged 17.3 days in the traction group and 2.2 days in the immediate-casting group (p < 0.001). Total estimated charges, at current rates, demonstrated an 83% greater patient charge in the traction group than in the immediate-casting group.

Trevorʼs disease: the clinical manifestations and treatment of dysplasia epiphysealis hemimelica

Trevors disease is a rare abnormality characterized by aberrant osteocartilaginous growth from an epiphysis. We describe six new cases from our institution. A patient with isolated tibial tuberosity involvement is described for the first time. Each patient was classified according to Azouz into localized (three), classical (two) and generalized (one) form. We recommend that parents be counseled regarding the progressive nature of this disorder owing to the chance of worsening deformity with surgical excision alone, and the need to be followed until skeletal maturity.

Treatment for unicameral bone cysts in long bones: an evidence based review

The purpose of this paper is to perform an evidence based review for treatment of unicameral bone cysts. A search of MEDLINE (1966 to 2009) was conducted and the studies were classified according to levels of evidence. This review includes only comparative Level I-III studies. The systematic review identified 16 studies. There is one level I study, one level II study and the remaining 14 studies are level III. Seven of the sixteen studies had statistically different results: three studies indicated that steroid injection was superior to bone marrow injection or curettage and bone grafting; one study indicated that cannulated screws were superior to steroid injections; one study indicated resection and myoplasty was superior to steroid injection; one study indicated a combination of steroid, demineralized bone matrix and bone marrow aspirate, and curettage and bone grafting were superior to steroid injection; and one study indicated that curettage and bone grafting was superior to non-operative immobilization. Based on one Level I study, including a limited number of individuals, steroid injection seems to be superior to bone marrow injection. As steroid injections have already demonstrated superiority over bone marrow injections in a randomized clinical trial, the next step would be a prospective trial comparing steroid injections with other treatments.

Cyst index: a nonpredictor of simple bone cyst fracture.

Purpose: Treatment is indicated for simple bone cysts (SBC) with high risk of fracture. The cyst index was described as a method to determine if a cyst is at high risk or low risk of fracture. Study Design: The cyst index of 32 femoral and humeral SBCs was determined by 8 reviewers. The risk group cyst index was compared with whether a fracture took place. Sensitivities, specificities, and positive and negative predictive values were calculated across varying cutoff levels. Intraobserver and interobserver reliability testing for 10 cysts was made. Results: Receiver operator curves demonstrate that no cutoff value gave an acceptable level of both sensitivity and specificity. The mean value for the cyst index was significantly different for different observers (P < 0.05). Conclusions: This study does not validate the cyst index to be an accurate predictor of fracture. The test has low intraobserver and interobserver reliability. Clinical Relevance: The cyst index cannot reliably discriminate between the patients that will fracture and those that will not.

Precordial Doppler evaluation of simple bone cyst injection.

Background: A randomized prospective trial of marrow-versus-steroids treatment of solitary bone cyst was ongoing. Protocol required contrast injection of the cyst. A subpopulation was noted to have large, rapid venous outflow of contrast material (omnipaque). Central embolization and resultant acute respiratory distress syndrome has been reported with bone marrow transplant. Particulate injection can result in bradycardia, low exhaled CO2, decreased SaO2 and voltage changes on electrocardiogram. Methods: Precordial Doppler can measure flow and turbulence centrally after a peripheral cyst injection. Our cases were monitored with precordial Doppler as well as heart rate, ETCO2, blood pressure, electrocardiogram, and pulse oximetry. Results: Five patients/7 injections were noted to have large and rapid outflow veins from solitary bone cyst. The Doppler showed increased signal in all 7 particulate injections (2 steroid injections, 5 bone marrow aspirates and cyst injections.) One marrow injection resulted in transient bradycardia and decreased blood pressure with no sequelae. One developed transient decrease in exhaled CO2. Conclusions: Rapid outflow has been reported in the past but precordial Doppler monitoring of injection into peripheral cysts is not reported. The potential for embolization with serious physiologic effects is a concern. Others have advocated injection of more particulate substances, such as calcium, sulfate, and demineralized bone matrix. This Doppler technique may be valuable for monitoring the potential harmful effects of these injections and lead to a better understanding of failure of cyst healing due to rapid outflow of material. Level of Evidence: Level IV case series with poor reference standard.

Protrusio Acetabuli in Marfan Syndrome: Indication for Surgery in Skeletally Immature Marfan Patients

The authors reviewed all patients in Shriners Hospital for Children, Honolulu, diagnosed with hyperlaxity of the joints (131 in total) for Marfan syndrome. The revised diagnostic criteria for Marfan syndrome were used for inclusion in this study. In the patients diagnosed with Marfan syndrome (n = 13), the incidence (n = 9) and indication for surgical intervention (n = 4) of protrusio acetabuli were evaluated by retrospective radiographic review, clinical findings, and family history. For the identification of protrusio acetabuli, the presence of an abnormal acetabular line position (>1 mm medial to the ilioischial line in boys, >3 mm in girls), a center-edge angle of Wiberg of 40 degrees or more, or crossing of the teardrop by the ilioischial line was used. The authors conclude that serial radiographic investigations, reinforced with a well-documented family history of symptomatic protrusio acetabuli, are needed to rule out progression of the deformity. When progression of the deformity is suggested in a skeletally immature Marfan patient, surgical intervention by closure of the triradiate cartilage is indicated, regardless of the absence of hip complaints or limitation of range of motion.

C-reactive protein response following pediatric orthopaedic surgery.

The purpose of this study was to describe the pediatric C-reactive protein (CRP) response following orthopaedic surgery, specifically addressing whether CRP values in children return to normal within 3 weeks as they do in adults. Children undergoing elective orthopaedic procedures had serum CRP values measured before surgery and then on days 3, 7, and 21 after surgery. These intervals were chosen to assess the rise, fall, and return to normal of CRP levels. Twenty-two children were studied. CRP levels on day 3 varied from normal to 22.2 mg/dL (mean 7.3 mg/dL), on day 7 they averaged 2.2 mg/dL, and at 3 weeks all values were normal. None of the patients had postoperative infections. The authors concluded that the CRP rise in children may be more varied than in adults. In children, CRP levels return to normal within 3 weeks after surgery. This information can be useful in identifying postoperative infections in children.

Pedicle rotation in scoliosis: a marker for occult intrathecal abnormalities.

Study Design. The Perdriolle method was used to assess retrospectively radiographic pedicle rotation for association with occult intrathecal abnormalities in patients with scoliosis. Objective. To determine if pedicle rotation can be predictive of underlying intrathecal abnormalities. Summary of Background Data. Scoliosis associated with intrathecal abnormalities is thought to produce less rotation than true idiopathic scoliosis. No supporting evidence was found in the literature. Methods. A consecutive series of patients with a presenting diagnosis of idiopathic scoliosis were reviewed for anteroposterior radiographs and spinal magnetic resonance imaging (MRI). A blinded single examiner evaluated radiographic curve parameters. MRI reports were reviewed for the presence or absence of intrathecal abnormalities. Results. A total of 78 MRIs included 15 intrathecal abnormalities and 63 normals. The abnormal MRI group had more males and apex left curves. Primary curve in the intrathecal abnormality group had a mean of 9.6° of apical vertebrae rotation compared to 17.7° in idiopathic curves (average 37° and 40° Cobb angles, respectively). Of angulation, 1° correlated with 0.21° and 0.34° of rotation in intrathecal abnormality versus no abnormality groups, respectively. Conclusions. Curves with occult intrathecal pathology had significantly less rotation than those without. Pedicle rotation assessment is a useful adjuvant for identifying scoliosis with intrathecal abnormalities.